Page 1 1. RADIOGRAPHIC EVALUATION 1001 Panoramic image (PAN) Maxillary sinuses Nasal cavity TMJ complex Mandibular canal visualization?bone anomalies (eg. radiopacity/radiolucency) Soft tissue abnormalities (eg. sialoliths, calcified lymph nodes) Other findings 1101 Intraoral images (FMX, PAX, BWX) Missing teeth For each caries class, list tooth # then surface Double-click HERE to display ADA Caries Classification System (CCS)-XR E1: E2: D1: D2: D3: Other caries: Radiographic calculus Radiographic periodontal defects PDL space or lamina dura abnormalities?bone anomalies (eg. radiopacity/radiolucency) 1201 General radiographic diagnoses (summarize) 1301 Additional imaging needed?
Page 2 2. HEAD & NECK EVALUATION 2101 Extra-oral Soft Tissue NO = No lesion/variations observed Facial asymmetry-significant variations? Yes No If yes, describe: Skin-lesions observed? Yes No If yes, describe: Thyroid gland-lesions observed? Yes No If yes, describe: Salivary glands-lesions observed? Yes No If yes, describe: Carotid pulse-any significant variations? Yes No If yes, describe: Lymph nodes-lesions observed? Yes No If yes, describe: 2201 Musculoskeletal Muscles of Mastication Asymptomatic-no issues reported Symptomatic-jaw pain or limitations reported If symptomatic, describe (familiar pain?, pain intensity?, referred to distant sites?) TMJ palpation R Lateral pole (Click Yes to select answers) Yes No Asymptomatic Symptomatic Click Crepitus L Lateral pole (Click Yes to select answers) Yes No Asymptomatic Symptomatic Click Crepitus Mandibular deviation upon maximum opening NO=Normal (<2mm) Yes No If Yes-Deviation/deflection to R (mm) If Yes-Deviation/deflection to L (mm) Double-click HERE to display TMJ Functional Measurements Diagram Mandibular Range-of-Motion measurements (reference teeth #8 & #25) OB-Overbite (vertical mm) Maximum inter-incisal opening (mm, include OB) OJ-Overjet (horizontal mm) Maximum protrusion (mm, include OJ) Maximum R excursion (mm) Maximum L excursion (mm) 2301 Cranial Nerve Screening Sensory/motor abnormalities observed: Y/N Yes No (if yes, complete Cranial Nerve Screening on Orofacial Pain form) 2999 Treatment suggestions based on findings
Page 3 3. ORAL SOFT TISSUE EVALUATION?3001 Intra-oral ST lesion observations: Lips Hard palate Soft palate Oropharynx Tongue Floor-of-mouth Buccal mucosa Gingiva/alveolar mucosa 3999 Treatment suggestions based on findings 4. INITIAL PERIODONTAL ASSESSMENT Double click HERE to display LSU Modified ADA/AAP Case Type Classifications 4101 PD Probing depths (generalized = more than 30% of sites) 0-3 mm 3-4 mm 5-6 mm > 7 mm 4201 XR Radiographic bone loss from CEJ (check all that apply) Yes No No bone loss < 2mm 2-3 mm (< 10%) 3-5 mm (11-30%) > 5 mm (>30%) 4301 Working Diagnosis (Check one) Yes No N/A (not applicable, edentulous) Gingival health Gingival health or gingivitis on a reduced periodontium Gingivitis (I) Mild periodontitis (II) Moderate periodontitis (III) Severe periodontitis (IV) (if yes, checkall) (if yes, check one) 4998 ADDITIONAL INFORMATION FOR THIS SECTION: 4999 Treatment suggestions based on findings
Page 4 5. OCCLUSAL EVALUATION 5001 Skeletal Skeletal Class (profile vertical) Mesognathic-Class 1 Retrognathic-Class 2 Prognathic-Class 3 Skeletal Harmony (frontal horizontal) Open (midface < lower face) Normal (midface = lower face) Deep (midface > lower face) 5101 Individual Arch Assessment Click on green? at bottom of form Copy and paste into answer text box?maxillary Arch Assessment Summary?Mandibular Arch Assessment Summary Inter-arch Relationships in Maximum Intercuspal Position (MIP) 5201 Horizontal MIP (Angle's Classification) Double-click HERE to display Angle's Classification Diagram Right Angle's Classification R molar/cuspid--class I Mesognathic R molar/cuspid--class II Retrognathic R molar/cuspid--class III Prognathic R molar/cuspid--n/a Left Angle's classification L molar/cuspid--class I Mesognathic L molar/cuspid--class II Retrognathic L molar/cuspid--class III Prognathic L molar/cuspid--n/a Incisor Position Labioversion, proclined as Angle's Class II Div 1 Retruded centrals, reclined as Angles Class II Div 2 Incisor position--n/a 5301 Vertical MIP (Occlusal Vertical Dimension)?OVD Assessment Summary Copy and paste into answer text box 5401 Transverse MIP (Crossbite) No crossbite Anterior crossbite Right posterior crossbite Left posterior crossbite (check one) 5998 ADDITIONAL INFORMATION FOR THIS SECTION: 5999 Treatment suggestions based on findings
Page 5 6. VITALITY EVALUATION 6001 Vitality evaluation needed? Yes No (check one) 6101 Symptoms affected by any of the following: heat, cold, sweets, biting, chewing, manipulation, head position, time of day, medication? 6201 Tooth clinical findings? 6301 Soft tissue clinical findings? 6401 XR tooth findings? 6501 XR attachment apparatus findings? 6601 Double-click HERE to enter pulp and periapical TEST RESULTS & DIAGNOSIS